Favorable Cost-effectiveness Ratio Research Articles

The economic evaluation of prevention – Let’s talk about values and the case of discounting

“Does prevention pay off?” is a question frequently directed at health economists, and, as they are economists, they usually respond “it depends”. The good news is that health economic evidence on prevention has steadily increased over the past years and a number of interventions have proven favourable cost-effectiveness ratios (Wang et al. 2001; Murray et al. 2003). The bad news is that this growth has been highly selective, and many of the studies lack quality. In a recent systematic review we found that the majority of economic evaluations that assessed interventions for primary prevention of cardiovascular disease are pharmacoeconomic studies of clinical prevention that target dyslipidemia and typically refer

Cost‐effectiveness of peginterferon alfa‐2a compared to lamivudine treatment in patients with hepatitis B e antigen positive chronic hepatitis B in Taiwan

Peginterferon alpha-2a (40KD), a new treatment option for patients with chronic hepatitis B (CHB), offers improved efficacy with a defined treatment duration compared with lamivudine, but at a higher cost. We undertook an economic evaluation of peginterferon alpha-2a from the perspective of the Taiwan Bureau of National Health Insurance to assess the clinical outcomes and costs of 48 weeks of peginterferon alpha-2a for the treatment of patients with hepatitis B e antigen (HBeAg)-positive CHB, compared to lamivudine treatment for 48 weeks. We performed a cost-effectiveness analysis using a state-transition Markov model simulating the natural history of HBeAg-positive CHB. Efficacy data were obtained from a randomized clinical trial of 820 patients (87% were Asian) comparing peginterferon alpha-2a to lamivudine. We modeled a hypothetical cohort of 32-year-old patients with HBeAg-positive CHB. Life expectancy, quality-adjusted life expectancy, lifetime costs ($NTD) and incremental cost-effectiveness ratios (ICER) were estimated. One-way sensitivity analyses were performed on all parameters in the model to evaluate uncertainty. Treatment with peginterferon alpha-2a compared to lamivudine resulted in higher total costs, but longer quality-adjusted life expectancy, yielding an ICER of $NTD 381 000 ($US 12,000) per quality-adjusted life year (QALY) gained. Although there is uncertainty associated with the prognosis of HBeAg-positive CHB, the ICER did not exceed $NTD 485,000 ($US 15,000) per QALY gained despite variation in the parameters used in the analysis. Our analysis suggests that 48-week treatment with peginterferon alpha-2a compared to 48-week treatment with lamivudine in HBeAg-positive patients offers life expectancy and quality of life benefits at a favorable cost-effectiveness ratio.

Cost-Effectiveness of Drop-in-Centres to Prevent HIV Among Injecting Drug Users, IDUs, in Karachi, Pakistan

Background: The HIV epidemic in Pakistan is at present concentrated among high-risk groups including IDUs. Pakistan has approx. 75 000 IDUs - 12 300 are living in Karachi. The HIV prevalence rate among the IDUs in Karachi is 26%. During 2005 and 2006 Pakistan Society, an NGO working for vulnerable populations in Pakistan, established three Drop-In-Centres, DICs, in Karachi including outreach services using motorbikes. At present 850 IDUs visit at a daily basis for clean needles, counselling and care services including detoxification (10%). Objectives: 1) To discuss the methodologies used to determine the cost-effectiveness of IDU interventions in Pakistan when up-scaling to 60% coverage as recommended by UNAIDS, 2) to examine how these interventions fair comparative to the findings from a literature review, and finally 3) to suggest policy options to improve efficiency of providing HIV preventive services that will keep the HIV epidemic from spreading into the general population. Methodology: The cost information was collected in May - June 2006. The costs included are financial and economic costs from the perspective of the provider. The Rapid Costing Approach, RCA, was used to generate total costs as well as the unit costs over five years under different up-scaling assumptions. The behaviour change for the IDU population in Karachi is derived from surveys undertaken in 2005/2006 and imputed into a dynamic mathematical model (IDU 2.4) with data from the IDU population in Karachi. The costs of the IDU interventions in Karachi is being compared with the findings from a literature survey on costing and cost-effectiveness studies in Asia and Eastern Europe, which is also characterized by HIV epidemics driven by IDUs and sex workers. Results: The results show unit costs of IDU interventions in the range of USD 74-105 per IDU/year ranging from 100% utilisation of capacity to 70%. The cost-effectiveness ratio is estimated at USD 78-242 per HIV over five years - the range covering different coverage of intervention (7-60%) and 3% or 6% discount rate, respectively. A comparison with results from Bangladesh (3 year time horizon) shows that the IDU interventions provide a relatively better cost-effectiveness ratio at USD 64-200 per HIV averted comparative to Karachi IDU interventions at USD 117-260. Both IDU approaches are very cost-effective by any measure at USD 2-25 per DALY gained. Discussions: The discussion includes how sensitive the results are to changes of key variables and what it will take to ensure such favourable cost-effectiveness ratio; the validity and reliability of the mathematical model; and finally what messages the result bring to the table of decision makers.

Cost-effectiveness of medical interventions to prevent cardiovascular disease in a sub-Saharan African country – the case of Tanzania

BackgroundThere is a high and rising prevalence of cardiovascular risk in sub-Saharan Africa, a development typical for countries in epidemiological transition. Contrary to recommendations in treatment guidelines, medical interventions to prevent cardiovascular disease are implemented only on a limited scale in these settings. There is a widespread concern that such treatment is not cost-effective compared to alternative health interventions. The main objectives of this article are therefore to calculate costs-, effects and cost-effectiveness of fourteen medical interventions of primary prevention of cardiovascular disease in Tanzania, including Acetylsalicylic acid, a diuretic drug (Hydrochlorothiazide), a β-blocker (Atenolol), a calcium channel blocker (Nifedepine), a statin (Lovastatin) and various combinations of these.MethodsEffect sizes were derived from systematic reviews or meta-analyses, and calculated as Disability Adjusted Life Years (DALYs). Data on drug costs were calibrated to a Tanzanian setting. Other recurrent and capital costs were derived from previous studies and reviewed by local experts. Expected lifetime costs and health outcomes were calculated using a life-cycle model. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability curves and frontiers. The potential impacts of uncertainty in value laden single parameters were explored in one-way sensitivity analyses.ResultsThe incremental cost-effectiveness ratios for the fourteen interventions and four different levels of risk (totally 56 alternative interventions) ranged from about USD 85 per DALY to about USD 4589 per DALY saved. Hydrochlorothiazide as monotherapy is the drug yielding the most favorable cost-effectiveness ratio, although not significantly lower than when it is combined in duo-therapy with Aspirin or a β-blocker, in triple-therapy with Aspirin and a β-blocker, or than Aspirin given as mono-therapy.ConclusionPreventive cardiology is not cost-effective for any patient group in this setting until willingness to pay exceeds USD 85 per DALY. At this level of willingness to pay, the optimal intervention is Hydrochlorothiazide to patients with very high cardiovascular risk. As willingness to pay for health increase further, it becomes optimal to provide this treatment also to patients with lower cardiovascular risk, and to substitute to more sophisticated interventions.

Measuring Preferences for Cost-Utility Analysis

Preferences for health are required when the economic value of healthcare interventions are assessed within the framework of cost-utility analysis. The objective of this paper was to review alternative methods for preference measurement and to evaluate the extent to which the method may affect healthcare decision-making. Two broad approaches to preference measurement that provide societal health state values were considered: (i) direct measurement; and (ii) preference-based health state classification systems. Among studies that compared alternative preference-based systems, the EQ-5D tended to provide larger change scores and more favourable cost-effectiveness ratios than the Health Utilities Index (HUI)-2 and -3, while the SF-6D provided smaller change scores and less favourable ratios than the other systems. However, these patterns may not hold for all applications. Empirical evidence comparing systems and decision-making impact suggests that preferences will have the greatest impact on economic analyses when chronic conditions or long-term sequelae are involved. At present, there is no clearly superior method, and further study of cost-effectiveness ratios from alternative systems is needed to evaluate system performance. Although there is some evidence that incremental cost-effectiveness ratio (ICER) thresholds (e.g. $US50,000 per QALY gained) are used in decision-making, they are not strictly applied. Nonetheless, as ICERs rise, the probability of acceptance of a new therapy is likely to decrease, making the differences in QALYs obtained using alternative methods potentially meaningful. It is imperative that those conducting cost-utility analyses characterise the impact that uncertainty in health state values has on the economic value of the interventions studied. Consistent reporting of such analyses would provide further insight into the policy implications of preference measurement.

Oral Antiplatelet Therapy in Secondary Prevention of Cardiovascular Events

A wide variety of oral antiplatelet trials have been carried out, and a large number of cost-effectiveness estimates based on them have been published. To assess the cost effectiveness of oral antiplatelet treatments in the prevention of cardiovascular events. A comprehensive literature search was carried out in PubMed and the Cochrane Library and the data reviewed. Cost-effectiveness or cost-utility studies of oral antiplatelets published since 2000 were selected. Cost-effectiveness analyses from the perspective of the UK NHS were then carried out using a Markov model with a 6-month cycle length and a lifetime horizon. Inputs from the CAPRIE, CHARISMA, (PCI)-CURE, CREDO, COMMIT, CLARITY, ESPS 2 and ESPRIT trials were included. All estimates of cost found (per event avoided, per QALY gained or per life-year gained) were included. Results were analysed in light of the National Institute for Health and Clinical Excellence (NICE) guidelines for the use of antiplatelets for the prevention of cardiovascular events and all estimates were updated to pound (year 2006 values) for easy comparison. Of the initial 141 studies found, 21 were included in the initial review. The literature and the Markov model subsequently used suggest that aspirin (acetylsalicylic acid) dominates placebo for the secondary prevention of cardiovascular events, as it is effective, is also less costly and is as well tolerated as placebo. Additionally, in periods or patients with elevated risk, more intensive treatment with clopidogrel (alone or together with aspirin) is cost effective compared with aspirin alone for the secondary prevention of ischaemic events. For secondary stroke prevention, combination therapy with aspirin and dipyridamole has a favourable incremental cost-effectiveness ratio (ICER) when compared with aspirin alone and, based on an indirect comparison, also when compared with clopidogrel. The cost-effectiveness estimates presented in this article support the NICE guidelines for the use of antiplatelets for the prevention of cardiovascular events. Based on these pharmacoeconomic data alone, aspirin should be prescribed for primary or secondary prevention among patients at high risk of cardiovascular events, dipyridamole for the secondary prevention of stroke (for a maximum of 5 years), and clopidogrel for the treatment of symptomatic cardiovascular disease or acute coronary syndrome (for a maximum of 2 years). The cost effectiveness of antiplatelets hinges on the patient's initial risk, the risk reduction associated with treatment, and the price of the treatment. Evidence suggests that the cost effectiveness of antiplatelets can be optimized by individualising the treatment decision based on patient risk and expected risk reduction.

Cost-effectiveness of Rosiglitazone Oral Combination for the Treatment of Type 2 Diabetes in Germany

To assess the cost-effectiveness of rosiglitazone in combination with other oral agents for the treatment of overweight and obese patients with type 2 diabetes in Germany. The Diabetes Decision Analysis of Cost--type 2 model was adapted for clinical practice and healthcare financing rules in Germany. The model was calibrated using Cost of Diabetes in Europe Type 2 study data and national statistics. The perspective is that of the sickness funds, and includes all hospital inpatient, ambulatory, rehabilitation, and diabetes therapy, other medications, and sickness leave. The model simulates lifetime treatment histories and associated health outcomes and costs for age and sex-matched cohorts of 1000 overweight and obese patients. The measures of effectiveness used in the analysis were life-years and quality adjusted life-years (QALYs). The combination therapy of rosiglitazone with metformin or sulfonylurea produces better glycaemic control than conventional care of metformin with sulfonylurea and insulin in most patients, extends the viability of oral therapy before requiring insulin, and typically leads to lifetime cost increases across all treatment types. The improvements in glycaemic control lead to survival gains and reductions in morbidity, because of the reduced risk of developing or progressing to later stages of complications. Improvements in morbidity and mortality generate additional QALYs. Costs and health outcomes combine to yield favourable incremental cost-effectiveness ratios, which fall below international 'willingness-to-pay' thresholds in the medium term. The model predicts that rosiglitazone in combination with other oral agents is a cost-effective intervention for the treatment of normal weight, overweight and obese patients with type 2 diabetes when compared with conventional care in Germany.

Cost-effectiveness of 4 Neonatal Screening Strategies for Cystic Fibrosis

The purpose of this work was to assess the costs of 4 neonatal screening strategies for cystic fibrosis in relation to health effects. In each strategy, the first test was the measurement of serum concentration of immunoreactive trypsin. The second step consisted of either a second immunoreactive trypsin test (strategy 1) or a multiple mutation analysis (strategy 2). In strategies 3 and 4, a third step was added to strategy 2: a second immunoreactive trypsin test (strategy 3) or an extended mutation analysis of the cystic fibrosis gene, that is, a denaturing gradient gel electrophoresis analysis (strategy 4). We conducted an economic-modeling exercise in the Netherlands based on published data and expert opinions. Subjects were a hypothetical cohort of 200 000 neonates, the approximate number of children born annually in the Netherlands, and we assessed the costs and number of life-years gained as a result of neonatal screening for cystic fibrosis. The costs and effects of changes in reproductive decisions because of neonatal screening were also assessed. Immunoreactive trypsin + immunoreactive trypsin had the most favorable cost-effectiveness ratio of 24,800 euro per life-year gained. Immunoreactive trypsin + DNA + denaturing gradient gel electrophoresis achieved more health effects than immunoreactive trypsin + DNA + immunoreactive trypsin at lower cost. The incremental costs per life-year gained of the immunoreactive trypsin + DNA + denaturing gradient gel electrophoresis strategy compared with the immunoreactive trypsin + immunoreactive trypsin strategy were 130,700 euro, whereas the incremental costs of the immunoreactive trypsin + DNA strategy compared with the immunoreactive trypsin + DNA + denaturing gradient gel electrophoresis strategy were 2,154,300 euro. When changes in reproductive decisions as a result of neonatal screening are also taken into account, neonatal screening for cystic fibrosis may lead to financial savings of approximately 1.8 million euro annually, depending on the screening strategy used. Cystic fibrosis screening for neonates is a good economic option, and positive health effects can also be expected. Immunoreactive trypsin + immunoreactive trypsin and immunoreactive trypsin + DNA + denaturing gradient gel electrophoresis are the most cost-effective strategies.

Cost-Effectiveness of Pharmacogenomics in Clinical Practice: a Case Study of Thiopurine Methyltransferase Genotyping in Acute Lymphoblastic Leukemia in Europe

Only a few studies have addressed the cost-effectiveness of pharmacogenetics interventions in healthcare. Lack of health economics data on aspects of pharmacogenetics is perceived as one of the barriers hindering its implementation for improving drug safety. Thus, a recent Institute for Prospective Technological Studies (IPTS) study, entitled 'Pharmacogenetics and pharmacogenomics: state-of-the-art and potential socio-economic impact in the EU' included an explorative cost-effectiveness review for a pharmacogenetic treatment strategy compared with traditional medical practice. The selected case study examined the cost-effectiveness of thiopurine methyltransferase (TMPT) genotyping prior to thiopurine treatment in children with acute lymphoblastic leukemia (ALL). Information for the cost-effectiveness model parameters was collected from literature surveys and interviews with experts from four European countries (Germany, Ireland, the Netherlands and the UK). The model has established that TPMT testing in ALL patients has a favorable cost-effectiveness ratio. This conclusion was based on parameters collected for TPMT genotyping costs, estimates for frequency of TMPT deficiency, rates of thiopurine-mediated myelosuppression in TPMT-deficient individuals, and myelosuppression-related hospitalization costs in each of the four countries studied. The mean calculated cost per life-year gained by TPMT genotyping in ALL patients in the four study countries was euro 2100 (or euro 4800 after 3% discount) based on genotyping costs of euro 150 per patient. Cost per life-year gained is expected to further improve following the introduction of the wider use of TMPT genotyping and the availability of lower cost genotyping methods. Our analysis indicates that TPMT genotyping should be seriously considered as an integral part of healthcare prior to the initiation of therapy with thiopurine drugs.

Urinary incontinence: Economic burden and new choices in pharmaceutical treatment

In the year 2000, an estimated 17 million community-dwelling adults in the United States had daily urinary incontinence (UI), and an additional 33 million suffered from the overlapping condition, overactive bladder. Estimates of the total annual cost of these conditions range up to 32 billion US dollar; the largest components are management costs and the expenses associated with nursing home admissions attributable to UI. In most cases, patients with UI can be treated with pharmaceutical agents, in addition to behavioral therapy. Until recently, pharmaceutical therapy for UI has been limited, especially because the adverse effects of available agents resulted in poor adherence to treatment regimens. Recent innovations in molecular design and new dosage forms of UI medications offer the promise of fewer and less severe adverse effects and, thus, better treatment outcomes for patients. Additionally, the availability of multiple agents within a therapeutic class offers health care providers a spectrum of choices with which to personalize treatment for each individual patient. New pharmacologic treatment options for UI have the potential to allow greater independence for older persons who reside at home and to delay or avoid the costs of admission to long-term care facilities. Alternate dosage forms, which include patches and sustained-release formulations, may benefit patients who have difficulty chewing, swallowing, or remembering to take medications. Although these newer products are generally more expensive than older forms of therapy, they typically have more favorable cost-effectiveness ratios. Access to these new medications for patients enrolled in public and private health care plans may help to reduce the economic and social burden of UI care.

Current impact of gene technology on healthcare: A map of economic assessments

Objectives It has been claimed that gene technology will induce revolutionary changes in healthcare. This paper investigates how and to what extent these changes have been economically assessed. Methods A generic framework was developed to distinguish between methodologically similar evaluations of healthcare technology. Methodological issues and the current state of economic evidence concerning human DNA technology were extracted from publications within these groups of evaluations. Results Economic evaluations of “ healthcare consisting of gene technology” were identified primarily for in vitro diagnostics for hereditary disease and others for pharmacogenetics and molecular pathology. “ Healthcare enabled by gene technology” is far more encompassing and includes, e.g., biotechnology drugs for which various health economic evaluations can be found. Yet here, the impact of gene technology intertwines with the impact of other technologies and is therefore hardly susceptible to evaluation. The fields of evaluation may be classified best according to the two dimensions “purpose” and “stage of development”. Current evaluations cover screening, diagnostic and treatment technologies in investigational, new and established stages. Apart from prenatal screening, healthcare consisting of gene technology was cost saving only for genotype tests replacing continuous phenotype tests and for one pharmacogenetic test. Conclusive evidence of favourable cost-effectiveness ratios is available only for few conditions. Conclusion Hypotheses about the impact of gene technology on healthcare must be explicit about the definition of “genetic” medicine. A general statement regarding healthcare enabled by gene technology is not possible. Based on current evidence, an era of healthcare consisting of gene technology built on widespread predictive testing is not desirable from a health economic viewpoint.

The Cost‐Effectiveness of Large Amalgam and Crown Restorations Over a 10‐Year Period

To assist clinical decision making for an individual patient or on a community level, this study was done to determine the differences in costs and effectiveness of large amalgams and crowns over 5 and 10 years when catastrophic subsequent treatment (root canal therapy or extraction) was the outcome. Administrative data for patients seen at the University of Iowa, College of Dentistry for 1735 large amalgam and crown restorations in 1987 or 1988 were used. Annual costs and effectiveness values were calculated. Costs of initial treatment (large amalgam or crown), and future treatments were determined, averaged and discounted. The effectiveness measure was defined as the number of years a tooth remained in a state free of catastrophic subsequent treatment. Years free of catastrophic treatment were averaged, and discounted. The years free of catastrophic treatment accounted for individuals who dropped out or withdrew from the study. Teeth with crowns had higher effectiveness values at a much higher cost than teeth restored with large amalgams. The cost of an addition year free of catastrophic treatment for crowns was 1088.41 dollars at 5 years and 500.10 dollars at 10 years. Teeth in women had more favorable cost-effectiveness ratios than those in men, and teeth in the maxillary arch had more favorable cost-effectiveness ratios than teeth in the mandibular arch. Neither the large amalgam or crown restoration had both the lowest cost and the highest effectiveness. The higher incremental cost-effectiveness ratio for crowns should be considered when making treatment decisions between large amalgam and crown restorations.

Bias in published cost effectiveness studies: systematic review

Objective To investigate if published studies tend to report favourable cost effectiveness ratios (below $20 000, $50 000, and $100 000 per quality adjusted life year (QALY) gained) and evaluate...

Re: Cost‐effectiveness of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early‐onset group B streptococcal disease

COBJECTIVE: To estimate the costs and effects of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease in the Netherlands. The treatment strategies include a risk-based strategy, a screening-based strategy, a combined screening/risk-based strategy and the current Dutch guideline. DESIGN: Cost-effectiveness analysis based on decision model. SETTING: Obstetric care system in the Netherlands. POPULATION/SAMPLE: Hypothetical cohort of 200,000 neonates. METHODS: A decision analysis model was used to compare the costs and effects of different treatment strategies with no treatment. Baseline estimates were derived from literature and a survey among parents of children affected by GBS disease. The analysis was performed from a societal perspective, and costs and effects were discounted at a percentage of 3%. Main outcome measures Cost per quality adjusted of life-year (QALY). RESULT: The risk-based strategy will prevent 352 cases of early-onset GBS for 5.0 million Euros, indicating a cost-effectiveness ratio of 7600 Euros per QALY gained. The combined screening risk-based strategy has comparable results. The current Dutch guideline resulted in lower effects for higher costs. The screening-based strategy shows the highest reduction in cases of early-onset GBS, however, at a cost-effectiveness ratio of 59,300 Euros per QALY gained. Introducing the polymerase chain reaction (PCR) test may lead to a more favourable cost-effectiveness ratio. CONCLUSION: In the Dutch system, the combined screening/risk-based strategy and the risk-based strategy have reasonable cost-effectiveness ratios. If it becomes feasible to add the PCR test, the cost-effectiveness of the combined screening/risk-based strategy may even be more favourable. hemicals / CAS: chlorhexidine, 3697-42-5, 55-56-1

Cost-effectiveness of outpatient treatment in depressive patients with escitalopram in Germany

We investigated the cost-effectiveness of escitalopram (10 mg daily dose) vs. venlafaxine XR (75 mg daily dose) in a German outpatient setting for the treatment of unipolar depression (MADRS score 20-34) over a period of 70 days. To assess the cost effectiveness of the two substances we combined data from physician's surveys and clinical response data; cost-effectiveness was calculated using a Markov model. In a second step we considered the therapeutic decisions of the attending physicians. Cost-effectiveness was indicated as costs per successfully treated patient. Escitalopram demonstrated a more favorable cost-effectiveness ratio than venlafaxine XR. The analysis of treatment patterns showed that attending physicians intervene fairly early if the chosen therapy is ineffective. Additional costs for the use of venlafaxine XR over those of escitalopram were estimated from Euro 7,446 to Euro 9.836 per successfully treated per patient. Hence escitalopram may be a cost-effective alternative to venlafaxine XR in outpatient care setting in Germany.

Efficient allocation of resources to prevent HIV infection among injection drug users: the Prevention Point Philadelphia (PPP) needle exchange program

The objective of this study is to determine the allocation of resources within a multi-site needle exchange program (NEP) that achieves the largest possible reduction in new HIV infections at minimum cost. We present a model that relates the number of injection drug user (IDU) clients and the number of syringes exchanged per client to both the costs of the NEP and the expected reduction in HIV infections per unit time. We show that cost-effective allocation within a multi-site NEP requires that sites be located where the density of IDUs is highest, and that the number of syringes exchanged per client be equal across sites. We apply these optimal allocation rules to a specific multi-site needle exchange program, Prevention Point Philadelphia (PPP). This NEP, we find, needs to add 2 or 3 new sites in neighborhoods with the highest density of IDU AIDS cases, and to increase its total IDU client base by about 28%, from approximately 6400 to 8200 IDU clients. The case-study NEP also needs to increase its hours of operation at two existing sites, where the number of needles distributed per client is currently sub-optimal, by 50%. At the optimal allocation, the estimated cost per case of HIV averted would be dollar 2800 (range dollar 2300-dollar 4200). Such a favorable cost-effectiveness ratio derives primarily from PPP's low marginal costs per distributed needle.

Health and Economic Consequences of Sevelamer Use for Hyperphosphatemia in Patients on Hemodialysis

Objectives The safety and efficacy of sevelamer hydrochloride in binding phosphate in patients with end-stage renal disease and its ability to attenuate the progression of cardiac calcification have been well documented but not the longer-term health and economic implications. Thus, a model of the predicted long-term consequences of sevelamer compared with calcium-based binders (acetate and carbonate) was developed. Methods Long-term cardiovascular implications of 1 year of treatment with phosphate binders in patients on hemodialysis are estimated based on the patient's demographics, comorbidities, and physiologic and renal parameters. The initial calcification score and expected changes over 1 year are derived using regression equations developed from the Treat-to-Goal study and translated to cardiovascular disease risk based on equations developed from a long-term cohort study. In this article, the implications of cardiovascular disease for life expectancy and medical costs are accounted for from a US payer perspective. Results The cardioprotective effect of sevelamer over 1 year is estimated to result in a 12% reduction in cardiovascular events compared with calcium acetate. In a population of 100 patients, the savings of $205,600 accrued due to avoiding nine cardiovascular events with sevelamer, largely offset the increased binder costs, leading to a favorable cost-effectiveness ratio of about $2200 per (discounted) life-year gained. Conclusions Although both binders provide equivalent phosphate binding capacity, the results indicate that the advantage of 1 year of treatment with sevelamer in attenuating the progression of calcification has important clinical and economic consequences, suggesting that this provides good value for money.

Cost-effectiveness comparison of current proton-pump inhibitors to treat gastro-oesophageal reflux disease in the UK

ABSTRACTObjective: Gastro-oesophageal reflux disease (GORD) is a recurring condition with many patients requiring long-term maintenance therapy. Therefore initial choice of treatment has long-term cost implications. The aim was to compare the costs and effectiveness of treatment of GORD (unconfirmed by endoscopy) with seven proton pump inhibitors (PPIs: esomeprazole, lansoprazole (capsules and oro-dispersible tablets), omeprazole (generic and branded), pantoprazole and rabeprazole), over one year.Design and methods: A treatment model was developed of 13 interconnected Markov models incorporating acute treatment of symptoms, long-term therapy and subsequent decisions to undertake endoscopy to confirm diagnosis. Patients were allowed to stop treatment or to receive maintenance treatment either continuously or on-demand depending on response to therapy. Long-term dosing schedule (high dose or step-down dose) was based on current market data. Efficacy of treatments was based on clinical trials and follow-up studies, while resource use patterns were determined by a panel of physicians.Main outcome measures: The model predicts total expected annual costs, number of symptom-free days and quality-adjusted life-years (QALY).Results: Generic omeprazole and rabeprazole dominated (i.e. cost less and resulted in more symptom-free days and higher QALY gains) the other PPIs. Rabeprazole had a favourable cost-effectiveness ratio of £3.42 per symptom-free day and £8308/quality-adjusted life-year gained when compared with generic omeprazole. Rabeprazole remained cost-effective independent of choice of maintenance treatment (i.e. proportion of patients remaining on continuous treatment versus on-demand treatment).Conclusions: Economic models provide a useful framework to evaluate PPIs in realistic clinical scenarios. Our findings show that rabeprazole is cost-effective for the treatment of GORD.

Cost-Effectiveness of Cognitive–Behavioural Therapy and Drug Interventions for Major Depression

Antidepressant drugs and cognitive-behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness -- Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression. The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods. All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below 10,000 Australian dollars per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from 17,000 Australian dollars to 20,000 Australian dollars per DALY) but still well below 50,000 Australian dollars, which is considered the affordable threshold. A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Cost‐effectiveness of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early‐onset group B streptococcal disease

To estimate the costs and effects of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease in the Netherlands. The treatment strategies include a risk-based strategy, a screening-based strategy, a combined screening/risk-based strategy and the current Dutch guideline. Cost-effectiveness analysis based on decision model. Obstetric care system in the Netherlands. Hypothetical cohort of 200,000 neonates. A decision analysis model was used to compare the costs and effects of different treatment strategies with no treatment. Baseline estimates were derived from literature and a survey among parents of children affected by GBS disease. The analysis was performed from a societal perspective, and costs and effects were discounted at a percentage of 3%. Main outcome measures Cost per quality adjusted of life-year (QALY). The risk-based strategy will prevent 352 cases of early-onset GBS for 5.0 million Euros, indicating a cost-effectiveness ratio of 7600 Euros per QALY gained. The combined screening risk-based strategy has comparable results. The current Dutch guideline resulted in lower effects for higher costs. The screening-based strategy shows the highest reduction in cases of early-onset GBS, however, at a cost-effectiveness ratio of 59,300 Euros per QALY gained. Introducing the polymerase chain reaction (PCR) test may lead to a more favourable cost-effectiveness ratio. In the Dutch system, the combined screening/risk-based strategy and the risk-based strategy have reasonable cost-effectiveness ratios. If it becomes feasible to add the PCR test, the cost-effectiveness of the combined screening/risk-based strategy may even be more favourable.